Nokea
A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved:
- A. Functional ability.
- B. Emotional stress.
- C. Alertness.
- D. Appetite.
Correct Answer: A
Rationale: Pallidotomy aims to improve functional ability by reducing symptoms like tremors and rigidity. Emotional stress, alertness, and appetite are not primary targets of this procedure.
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An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client?
- A. Use a nightlight in the bathroom.
- B. Keep all four side rails up at all times.
- C. Place the client in a room with a camera monitor.
- D. Place the client in a room with a camera monitor.
Correct Answer: A
Rationale: A nightlight reduces fall risk by improving visibility during nighttime bathroom trips, suitable for an alert client. Four side rails are a restraint and unsafe.
A nurse is assessing a group of clients. Which clients are at risk for vasospastic disorder (Raynaud's phenomenon)?
- A. Young women
- B. Old women
- C. Old men
- D. Young men
Correct Answer: A
Rationale: Young women are at highest risk for Raynaud's phenomenon, particularly primary Raynaud's, due to hormonal influences and higher prevalence of autoimmune conditions. While men and older individuals can develop it, young women are most commonly affected.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is performing discharge education for a 31-year-old female client.
Item 1 of 1
Progress Notes Orders
1710: The client has pelvic inflammatory disease and bacterial vaginosis. Will discharge the client home with antibiotics and with the instruction that the client should follow-up with her primary physician in two weeks.
The nurse is teaching a client about their prescribed medications. For each education statement, click to specify if the statement is relevant to metronidazole or doxycycline.
- A. You will need to use a backup method of contraception.
- B. Avoid consuming and using products with alcohol.
- C. You may experience a darkening of your urine.
- D. Do not take this medication with food or drinks containing calcium.
Correct Answer: A,B,C,D
Rationale: A (Doxycycline): Doxycycline can reduce the effectiveness of hormonal contraceptives, requiring a backup method. B (Metronidazole): Alcohol should be avoided with metronidazole due to a disulfiram-like reaction. C (Metronidazole): Darkening of urine is a side effect of metronidazole. D (Doxycycline): Calcium-containing foods/drinks reduce doxycycline absorption.
Which dietary modification is appropriate for a client with calcium oxalate stones?
- A. Increase dairy intake.
- B. Limit spinach consumption.
- C. Reduce fluid intake.
- D. Eat more red meat.
Correct Answer: B
Rationale: Spinach is high in oxalates, which contribute to calcium oxalate stone formation.